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The Prescribers

Medicare’s failure to monitor what doctors are prescribing has wasted billions of taxpayer dollars on excessive use of brand-name medication and exposed the elderly and disabled to drugs they should avoid.

Citing a ProPublica investigation, Iowa Republican Charles Grassley said that if Medicaid and Medicare don’t share information on bad doctors, patients could be at risk. (Mark Wilson/Getty Images)

A key U.S. senator sent letters to all 50 states this week asking how they sanction doctors in their state health programs and whether they alert the federal government when they do.

In his letters, Sen. Charles Grassley, R-Iowa, cited examples from a ProPublica report last month that found doctors who had been kicked out of state Medicaid programs for the poor were able to continue prescribing drugs to elderly and disabled patients in Medicare.

In 2005, for example, Florida booted Dr. Enrique Casuso from its Medicaid network using a provision that allows it to end contracts without cause on 30 days' notice. A memo justifying his removal said Casuso was seeing up to 81 Medicaid patients a day in addition to his non-Medicaid cases. Investigators found cases in which he lacked "awareness or oversight of the medication prescribed."

A copy of Casuso's termination letter was sent to Medicare. But Casuso continues to prescribe in Medicare's drug program, known as Part D, ProPublica reported.

In 2010, he prescribed more antipsychotics to elderly patients – 8,900, including refills dispensed – than any other doctor in the country. Many of those went to patients with dementia even though warnings from the Food and Drug Administration say the drugs increase the risk of death in such patients.

Casuso defended his prescribing, telling ProPublica the drugs were necessary to keep his patients safe and to calm them.

Physicians can be terminated from Medicaid for a variety of reasons. If they are terminated with cause, the state must prove misconduct. A termination without cause doesn't require any burden of proof. It may be because a doctor has stopped seeing Medicaid patients or because it is a quicker way of severing ties with a doctor suspected of wrongdoing.

The concern, Grassley wrote, is that while states use "without cause" terminations to quickly remove doctors from their Medicaid networks, the actions are not considered disciplinary and can't be used against doctors by Medicare. Terminations with cause, which are formal sanctions, can take much longer because they can be appealed.

"States' current practice of without cause termination from Medicaid may speed their ability to protect Medicaid patients, but it can expose Medicare recipients to potentially unsafe medical treatment and keeps tax dollars flowing to unworthy providers," wrote Grassley, the ranking Republican on the Senate Judiciary Committee.

Medicaid is jointly funded by states and the federal government, but is run by the states. Medicare is run by the federal government.

Grassley asked each state Medicaid program to indicate how it determines when to use the "without cause" provision and how it informs Medicare of its actions, if at all. Once states respond, Grassley plans to ask Medicare whether and how it acts on this information.

Physicians can continue to prescribe in Medicare unless they have been formally excluded from the program.

This is not the first time Grassley has questioned how Medicaid monitors prescribing by physicians and others. In 2010, he sent letters to all states asking for the names of the top prescribers of painkillers, antianxiety drugs and antipsychotics in their Medicaid programs. He followed up last year to ask whether the states had cracked down on those who wrote large numbers of prescriptions.

The senator also has focused on doctors' ties to drug companies. He was a key proponent of the Physician Payment Sunshine Act, which requires all drug and medical device makers to make public their payments to doctors beginning next year. And in 2009, he sent letters to prominent medical organizations seeking details about their industry financial support.

Justin Senior, the deputy secretary of Florida's Agency for Health Care Administration, said earlier this year that the ability to terminate a doctor's Medicaid contract without cause is "a tool that we can use when we see someone we feel might be doing something that is inappropriate."

In Florida, if physicians are expelled for cause from Medicaid, they cannot renew their state medical licenses. This can make the legal battle over such a termination much fiercer.

But Senior said that the physicians who are removed without cause have no blemish on their record. "They still have a license to practice medicine," he said. "They can happily make a living billing Medicare, Blue Cross ... billing whoever is willing to do business them."

Medicare could use these cases as tips to pass onto its own fraud investigators.

In his letter, Grassley cited two other examples from ProPublica's report:

Chicago psychiatrist Michael Reinstein wrote an average of 20,000 prescriptions for the antipsychotic clozapine in Part D each year between 2007 and 2009, and another 14,000 in 2010. Last year, he was suspended from Illinois Medicaid, and the Department of Justice has sued him for fraud. But he remains able to provide services under Medicare. Reinstein has treated patients at more than 30 Chicago-area nursing homes and long-term care facilities. He has defended his prescribing in media interviews.

Miami psychiatrist Fernando Mendez-Villamil was terminated without cause from Florida Medicaid in 2010 amid questions about his prescribing of mental health drugs. The Florida medical board also has accused him of giving patients as young as 3 a variety of such drugs without properly diagnosing or monitoring them. He remains eligible to prescribe in Medicare. His lawyer has said his client had done nothing wrong.

The Centers for Medicare and Medicaid Services, which oversees both programs, did not respond to a request for comment. Officials have previously declined to comment on the physicians named in this story.

In a statement, Grassley said he wants to "get first-hand information" to make sure actions taken by Medicaid programs don't leave Medicare patients at risk.

7 comments

This article makes me wonder whether we should have some nonpartisan office inform us, the voters of a certain district, whenever one of our elected representatives does or says something terminally stupid or embarrassing. For example, should they ask really stupid questions during a hearing, signifying that they know nothing about the topic at hand, or get up on the floor of the House or Senate and say things that are patently false and that make everyone cringe at the sheer stupidity of the remark. It would be great to have a variety of notices, sort of the way the weather folks notify us of the size of a storm, or the fact that one is soon to hit.

How about investigating bad heath insurance companies? Just do a web search for Kaiser Permanente & lawsuits & complaints. The number is staggering. The cases are heartbreaking. I am trapped in Kaiser Medicare HMO and HATE it. I would be scared to have surgery in one of their hospitals.

It’s none of their damn business! State Medical Boards are witch - hunting bastards as it is. None of this information should ever be in the hands of ignorant uninformed public entities. It is dangerous to everyone.

Leslie, you can add Humana to that list of bad health insurance companies. My Mother had a CVA and they stopped paying for her rehab after 32 days. They said she wasn’t improving fast enough. This is in violation of a class action lawsuit, Jimmo vs Sebelius. The IME agreed with Humana. Looks like a cozy arrangement. Why do we have courts and laws if these companies can break the law and no one holds them accountable? I have been appealing for 2 months to every government agency I can and I keep coming up against “brick walls”.

Richard, we used to call them “reporters.” You can see pictures of them in very old books, and probably at the ProPublica offices.

However, it turns out that it’s easier to sell controversy than fact to a wider audience, it’s better short-term business to report on “celebrities” nobody has ever head of, viral videos, and the new iPhone than actual news.

That makes me think, though: If part of the bargain for broadcasting spectrum is news in the public interest, and the news isn’t remotely in the public interest (or news), is there some way we can reclaim that spectrum for something more productive?

I did a web search for <Kaiser+lawsuits+complaints> and the results were horrifying. There are so many class actions, personal injury lawsuits, employee/employer lawsuits, etc., etc. that I was truly shocked. And still they go on doing the same thing AND MEDICARE GIVES THEM A TOP RATING. Why? When I queried Medicare by letter I received no response. I asked them to tell me the criteria they use in their polling and how frequently they poll. No response. The medical situation in this country is criminal and nothing will change until the public noisily demands change from Congress and Obama. As long as we the public tolerate this it will continue. Health care SHOULD NOT BE FOR PROFIT! Organize!

I did a web search for Kaiser+lawsuits+complaints and the results were horrifying. There are so many class actions, personal injury lawsuits, employee/employer lawsuits, etc., etc. that I was truly shocked. And still they go on doing the same thing AND MEDICARE GIVES THEM A TOP RATING. Why? When I queried Medicare by letter I received no response. I asked them to tell me the criteria they use in their polling and how frequently they poll. No response. The medical situation in this country is criminal and nothing will change until the public noisily demands change from Congress and Obama. As long as we the public tolerate this it will continue. Health care SHOULD NOT BE FOR PROFIT! Organize!

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